In September, eight mothers with their malnourished children climbed the tall gate of the Nutrition Rehabilitation Centre in Malkangiri town in Odisha in an attempt to run away from the facility past midnight. The centre is a 20-bed facility meant to accommodate undernourished children for at least two weeks to help them gain optimal weight. Between August and October this year, 119 women have ran away from the centre.

At most times the beds lie vacant, but since the outbreak of Japanese encephalitis in the district, the centre has been running full. Ninety threechildren have died in the district hospital with Acute Encephalitis Syndrome, a condition of brain inflammation caused by both bacterial and viral infections. Of the 93 children who died, 32 have tested positive for the Japanese encephalitis virus from September to October 14, this year.

Ever since the outbreak made national headlines, local health workers, under pressure from the state government, have been rushing malnourished children to the centre. These children do not necessarily suffer from encephalitis, but their weakened bodies are more susceptible to infections, and bringing them to the centre is seen as a way to protect them.

In the last week of October, the rooms at the centre were packed. Thirty eight infants and their mothers squeezed into space meant for 20. There were not enough cots. Most women slept on the floor with their newborns. There was only one bathroom.

According to the Nutrition Rehabilitation Centre guidelines, such facilities should have attached toilets, and even a breastfeeding demonstration space. But the staff at the centre had not heard of the guidelines.

Medicine room at Nutrition Rehabilitation Centre. The centre does not have a breastfeeding demonstration room. Photo: Priyanka Vora.

Unsurprisingly, some of the women decided to escape. “They ran away and went a few kilometres, when the police spotted them and brought them back,” said Anusaya Panigrahi, the health officer who runs the facility. Some women, however, were so determined that the next morning, they slipped away a second time and could not be brought back. Since then, the facility keeps the gates locked even during the day. The mothers are not allowed to go outside.

The Nutrition Rehabilitation Centre in Malkangiri where children sleep on floors instead of on cots. Credit: Priyanka Vora.

Nutrition determines survival chances

Seven out of ten children in Malkangiri are underweight, according to the 2014 Annual Health Survey report. The same report found that the district ranked third in the country among 100 districts that have the highest prevalence of underweight children under the age of five.About 33.4% of children in Malkangiri have low weight for height, which is classified as wasting and represents acute under nutrition caused by a lack of food. Wasting is predictor of mortality.

The district officials dismissed the possibility of malnutrition playing a role in the deaths of children who succumbed to Japanese encephalitis. “Malnutrition was not established as a cause of death,” said Dr US Mishra, chief district medical officer at Malkangiri.

Another medical officer in the district, however, admitted that most children who died of Japanese encephalitis were malnourished. “If I say this in the public, the government will not spare me,” he said, requesting anonymity. He added that many children would have been able to fight the Japanese encephalitis virus if they had been well nourished.

“Not all children who have Japanese encephalitis are dying,” he explained. “We are giving all the same medical treatment. What is the distinguishing factor is their immunity, which is dependent on their nutritional status.”

Using deceit to treat

Six-month-old Ganesh Madkami was brought to the Nutrition Rehabilitation Centre with his mother Bhime Madkami. He had what doctors call a case of “severe wasting”. He weighed just 2.9 kg ­– the optimal weight for a newborn and not for an infant at six months. The Accredited Social Health Activist or ASHA brought the child to the facility after telling the mother that they would have to stay there for only three days.

“We have to lie,” said the ASHA. “If I had told her that they will need to be in the facility for at least 15 days, she would have never agreed to come.”

“Even when the ambulance arrived, she was not ready to come,” the ASHA worker added.

The reasons for Madkami’s fear of the Nutrition Rehabilitation Centre were evident from the conditions inside. In some rooms, there was no space to walk between the mattresses laid out on the floor. The women and children had not been provided with sheets to cover themselves on cold nights. Such centres, according to the union health ministry’s guidelines, should have a child-friendly infrastructure with walls painted in bright colours. Only one section of the Malkangiri centre was neatly painted. The rest was made up of dull-looking halls crammed with rows of floor beds.

Floor beds at the Nutrition Rehabilitation Centre in Malkangiri where mothers and children adjust in small rooms. Photo: Priyanka Vora.

It was afternoon when I visited the centre, and the helpers started furiously sweeping the soiled floors. The women said the floors had not been swept for two to three days.

“I was scared to come here,” said Madkami, whose husband works in the neighbouring state of Andhra Pradesh. Malkangiri is in the southern part of Odisha and shares borders with Andhra Pradesh, Chhattisgarh and Telangana. Hence, many villagers from Malkangiri go to the neighbouring states in search for employment.

Madkami herself works as a labourer in the paddy fields within Malkangiri and lives alone in her home in Dupenkonda village. Like her baby, she is also undernourished and of slight built. She speaks a dialect that both the ASHA worker and the officer in charge of the centre do not understand.

“We can’t really explain much to them as I don’t speak their language,” said Panigrahi, who, in order to convince mothers like Madkami to stay, tells them that the police will arrest them if they try to run away.

The mother and child’s poor health raises questions about the implementation of the Integrated Child Development Scheme – a central government programme aimed at addressing the problem of undernutrition. “We provide food to children, pregnant and lactating mothers at the anganwadi,” said the ASHA worker. Madkami never came to collect her food, she said.

When asked, Madkami said that villagers had advised her against consuming food provided by the government. “I was told not to eat the food,” she said carrying her frail son with his distended belly on her hip. “Everyone says that I will fall ill, if I eat this food.”

Food being served at the Nutrition Rehabilitation Centre in Malkangiri in Odisha. Photo: Priyanka Vora.

A senior official from the state government said that there have been several complaints about children and women not accepting the food. “The food is cooked by the helper in the anganwadi and served to the villagers. The government can’t go and feed the children,” said the official defending the system.

According to Pradeep Pradhan, a right to food activist in Odisha, “The anganwadi system has been activated following the outbreak. Before the outbreak, most anganwadis were shut,” said Pradhan adding that the quality and quantity of food served is extremely bad.

Pradhan and his team had discussion with adivasis living in hamlets of Malkangiri to understand the problem of chronic hunger despite the Integrated Child Development Scheme. “There are two things. Either the program is not good enough or the implementation is bad. Many adivasis have told us that they feed the take home ration to their pigs because they don’t like the taste of it,” said Pradhan. “The government has not bothered to check whether the food they are trying to feed these children is good enough for their own.”

A reluctant administration

The Nutrition Rehabilitation Centre is managed by the only child specialist in the district, Dr Santosh Mishra. “He comes to the centre when he gets time from his hospital duty,” admitted Panigrahi. “He tries to take a round at least once in a day.” Mishra also works at the district headquarters hospital of Malkangiri where he is responsible for treating children with Japanese encephalitis and malaria.

According to the National Rural Health Mission guidelines, the Nutrition Rehabilitation Centre should have a doctor to monitor the progress of each child. Of the 103 sanctioned posts of doctors in the district, only 37 have been filled. The district also does not have enough nurses who form the backbone of rural healthcare. Only 43 of 122 sanctioned positions of nurses have been filled. “This is a punishment district,” said an official working in the health department. “Malkangiri’s performance is bad because none of the officials want to work here.”

Dr Mohammad Hussain started work at the community health centre in Kalimela in Malkangiri in October. “I was supposed to join here last year but I didn’t want to. It is a red zone,” he said, referring to the Maoist presence in the district. In the last week of October, 24 alleged Maoists were killed in a gunfight with the security forces. Government employees, including health workers, are reluctant to venture into the villages, even those that are far away from the arena of conflict.

“Government officers are always a target,” said Hussain.

While the district is grappling with the manpower shortage, it is also facing budget cuts. The National Health Mission budget for Malkangiri has dropped from Rs 22.37 crore in 2014-’15 to Rs 19.19 crore in 2015-’16.

A crisis of hunger

The budget cuts will only worsen the poor health infrastructure, which has repeatedly failed to identify and treat sick children early.

Five-year-old Radhika Modli was admitted to the district headquarters hospital’s intensive care unit. “I thought she had died,” said Lakhmi Modli, her grandmother who brought her to the hospital in a bus. “Her body was very warm so I decided to get her to the hospital.”

When asked why Radhika looked malnourished, Modli said in a trembling voice, “We used to give her food but she didn’t eat.”

Panigrahi, the village health worker, explained: “What they get at home is not enough.”

Rice and dal is served to children at anganwadis in Malkangiri in Odisha with two eggs. Photo: Priyanka Vora

Most families in Malkangiri including Radhika’s have two meals consisting of rice and some lentils. “Sometimes, there is not enough food, yet we try feeding the children, but she would just not eat,” said Modli. “We can’t force her to eat.”

Radhika is about 6 kg underweight at just 11 kg. Suspecting that she had Japanese encephalitis, doctors had sent her blood samples for testing. The nurse in charge of Radhika’s ward was worried. “I am not sure that she will survive until the test report arrives,” she said.

This is the final part in a series on why the government failed to prevent an encephalitis outbreak that has left nearly 100 children dead in a forgotten, impoverished district of Odisha. Read the rest of the stories here.

This reporting project has been made possible partly by funding from the New Venture Fund for Communications project, which receives support from the Bill & Melinda Gates Foundation.

Snippets of wisdom on the health care industry by Dr. Kevin Lofton

His sessions stressed on the importance of patient centric healthcare.

At the Hospital Leadership Summit 2017, Dr Kevin Lofton, CEO Catholic Health Initiatives, spoke on the need to focus on patient experience, the role of the leader and shared some ideas from the practices of his own hospital chain. Here are some snippets from Dr Lofton’s presentation that will provide some food for thought. The Bringing Health to Life content hub contains his and many other insights and best practices for healthcare delivery.

The two kinds of willing patients

During the summit, a consensus emerged that the health care industry needs to learn customer centricity from other industries. However, the health care industry is unique in several ways and one of the fundamental differences is the nature of its customer. Dr Lofton spoke about how the customer i.e. the patient in the health care industry is different by way of motivation. He reminded the gathering that nobody willingly seeks out a doctor.

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The paradigm shift needed in health care

Dr Lofton emphasised that patient centricity needs to become a part of the very philosophy of a health care facility, a philosophy that drives every action and motivates every employee in the organisation. He described this revaluation of purpose as a paradigm shift. Dr Lofton spoke about how patient centricity starts much before the patient walks into the hospital, that the patient’s tryst with the health care system starts before a visit to the doctor is warranted. In this clip, Dr Lofton provides an example of one such paradigm shift for health care providers.

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At the 2017 Hospital Leadership Summit, Dr Lofton shared several such insights from his experience in the US health care system. He emphasised especially on the need of empathy alongside clinical skill among health care providers.